April 13, 2012

Area(s) of Interest:

Early this month, the state Department of Health Care Services (DHCS) announced that four California counties – Los Angeles, Orange, San Diego and San Mateo – have been selected to serve as pilot territories for a plan to shift “dual eligibles” into managed care for both their Medicare and Medi-Cal services.

If the Legislature approves the Governor’s proposed State Budget as written, six additional counties – Alameda, Contra Costa, Riverside, Sacramento, San Bernardino and Santa Clara – would be added to the pilot projects.

The announcement means that, in at least four counties, dual eligibles – those meeting income qualifications for Medi-Cal as well as age or disability qualifications for Medicare – will begin receiving services through the existing managed care plans in their respective counties.

These plans will be responsible for coordinating benefits, negotiating rates with providers and paying for the care of enrollees. Additionally, dual eligible patients will be “passively enrolled” into the new managed care system; patients must take action to opt of the program.

The shift can present considerable problems to physicians and patients in these counties, particularly those who are not currently contracted with the county’s managed care plan.

Take action

The pilot project is subject to two 30-day comment periods, with the initial comment window closing on May 4. The California Medical Association (CMA) asks that you provide input no later than Friday, April 27, so that we can incorporate your thoughts.

Physicians and county medical societies can play a crucial role in helping CMA document issues with plan contracting and negotiations during the rollout of this pilot program so they can be brought to the attention of DHCS and the Department of Managed Health Care.

CMA is asking physicians to be proactive in educating their dual eligible patients about their options.

If you or your members are having difficulties with plan contracting, please contact David Ford in the CMA Policy Center at (916) 551-2554 or dford@cmanet.org, or Frank Navarro in the Center for Economic Services at (916) 551-2046 or fnavarro@cmanet.org.